Change Impact Assessment Template

• Conducted on

  Date

• Prepared by

• Location
  Address

General Change Information

• Name of change

• Change request number

• Description of change

• Reason for change

• Change type

  Minor

  Major

  Emergency

• Project / Department

Goal of the Change Impact Assessment

• How could this change impact assessment help your business and your employees?

• What is the intended result, effect, or output of this change impact assessment?

Scope of the Change Impact Assessment

• What's included in this change impact assessment?

• What’s not included in this change impact assessment?

Change Impact Areas

• Affected Business Units/Departments

• Affected Systems/Applications

• Affected Processes

• Affected Stakeholders

Risk Assessment and Change Impact Analysis

Potential Risk

• Risk Description

• Risk Likelihood

  Very Likely

  Likely

  Unlikely

  Highly Unlikely

• Initial Strategy

• Does it have an impact on business operations?

  Yes

  No

• Foreseeable Impact

• Does it have an impact on the financial side?

  Yes

  No

• Estimated Cost

• Budget Allocation

• Potential Financial Benefits

• Does it have an impact on the company's resources (i.e., personnel, technology, machinery)?

  Yes

  No

• Required resources

• Resource availability

Sign off

• Signature

  Sign